Vital health care services for more than 17 million of the nation’s most vulnerable citizens could be on the chopping block if the Republican health care bill becomes law.
If Medicaid home and community-based services are cut for children with special needs and adults and seniors with disabilities, many would either end up in costly nursing homes, require more assistance from struggling family members or simply do without the care that allows them to live independently.
Many of these low-income patients are functionally and cognitively impaired. They require home health aides, personal care attendants and day care programs to help with basic activities like eating, dressing, bathing and mobility.
Medicaid, the state-national health care plan for poor people and those with disabilities, is the largest public provider of these non-medical services, covering 30 percent of working-age adults with disabilities like cerebral palsy, mental illness, and traumatic brain and spinal cord injuries.
Unlike coverage for nursing home care, which is mandatory under Medicaid, home care services for the elderly and people with disabilities are optional.
Patient advocates fear that states will trim those optional Medicaid services if the program faces the 10-year, $880 billion cut in federal funding that the GOP health care bill proposes.
If the legislation becomes law, and states roll back their home and community-based services, many Medicaid patients with special needs and disabilities will end up in nursing homes, said David Certner, legislative policy director at AARP.
“This really threatens the ability of people to live independently in their homes,” Certner said. “We can take care of three people at home for the cost of one person in a nursing home, so it’s bad policy and it’s bad in terms of what people prefer.”
People with disabilities make up 15 percent of Medicaid enrollees but account for 42 percent of program spending because of their costly care, according to the Kaiser Family Foundation.
Faced with a loss of services, other home care patients would require more support from family members, who “are already carrying a huge load for their loved ones,” said Alice Dembner, senior policy analyst at Community Catalyst, a national advocacy group for vulnerable patients.
“That results in real effects in the economy, because you have lost wages and lost productivity from the folks who are now trying to balance more care of their family members than perhaps they can handle,” Dembner said.
The GOP bill moves Medicaid from an open-ended entitlement program to one with capped funding based on the number of enrollees.
That “per capita” funding formula wouldn’t keep pace with Medicaid’s current spending growth, leaving states to either make up the funding shortfall or cut costs by limiting enrollment, cutting services or lowering payments to Medicaid providers.
Many home care providers already don’t participate in Medicaid because the payments are so low, said Howard Bedlin, vice president for public policy and advocacy at the National Council on Aging.
“If this $880 billion cut and per capita cap goes into place, you’re going to see even lower payment rates” for home care workers, Bedlin warned. “These folks are getting minimum wage in some states without benefits and that could get even worse.”
Spending for Medicaid home and community-based services has grown dramatically in recent years because they save money by keeping people out of expensive institutional care. The services accounted for 53 percent of Medicaid spending on long-term care in 2014, up from just 18 percent in 1995, according to Kaiser.
In 2013, 640,000 people were on waiting lists for Medicaid home care services, Bedlin said. The demand for caregivers will only increase as the baby boomers, born from 1946 to 1964, continue to age.
Adults 80 and older, who are more likely to suffer life-altering impairments, are the fastest-growing slice of the older adult population.
That’s why the number of home health aides is expected to grow 38 percent from 2014 to 2024, faster than the average for all occupations, according to federal estimates.
And filling those jobs will be hard because of the high turnover among home care workers, who often leave for other low-paying jobs in fast food and retail.
“It's exceedingly difficult to find workers that are willing to take these jobs," said Stephen Campbell, policy research associate at the Paraprofessional Healthcare Institute, which advocates for the nation’s 2.2 million home-care workers. “They do this work out of a deep-seated sense of altruism. But at the end of the day, sometimes the situation can become untenable and they just have to leave.”
Bedlin, of the National Council on Aging, said he expects GOP congressional leaders to amend the bill in order to counter the mounting criticism of the legislation following the CBO report last week. The full House of Representatives is expected to vote on the measure this week.
“Whether it can get through the Senate is a whole other story,” Bedlin said.